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Left behind by Obamacare, and the state

By Misty Williams - The Atlanta Journal-Constitution

Karen LaBar is 41 and has never had a mammogram. She has high blood pressure but no doctor to attend to it. She works hard providing home health care to others but has no health care of her own.

And here’s the kicker: as President Barack Obama exults in the 7.1 million signups for his health plan, there will be no signup for LaBar. She’s too poor.

Statewide, more than 400,000 of Georgia’s poorest, most vulnerable citizens have been left behind by the health care law that was supposed to benefit them the most. Georgia chose not to expand Medicaid, as envisioned by the Affordable Care Act, creating a gap into which these hundreds of thousands fall. Those in the gap make too much money to qualify for Medicaid but too little to get federal tax credits to help buy coverage on the Health Insurance Marketplace.

The result: A parent of three who makes $10,000 a year can’t get a tax credit. A single person who makes $46,000 a year can.

The people in the gap are young and old, healthy and ailing. They are parents and workers, black and white. They live in metro Atlanta and rural communities across Georgia. They put food on the table for their families and put off doctor visits for themselves.

They are uninsured and likely to stay that way.

LaBar, a mother of five, lost her insurance four years ago when she and her husband divorced. She makes $10 an hour as a home health aide but doesn’t get insurance through work. Her paychecks cover the electric bill, rent, food and other necessities. They don’t come close to covering the $300 or more a month that health insurance would cost her.

Her four children who still live at home, ages 5 to 15, are covered by Medicaid. When LaBar first visited HealthCare.gov, she assumed that making so little — $12,000 to $13,000 a year — would qualify her for financial help to make insurance affordable. She was wrong.

As a household of five, she would have to make at least $27,910, equal to 100 percent of the federal poverty level, to be eligible for tax credits. Meanwhile, had the state decided to expand Medicaid, she would have qualified to enroll in that.

“I know people that get Medicaid and they don’t work,” LaBar said. “They sit at home and collect a check and that irritates me. I’m contributing to society. I pay taxes. It just doesn’t seem quite fair.”

Deal: Expansion would endanger education

It wasn’t supposed to be this way.

The Affordable Care Act’s creators envisioned that the nation’s poorest people wouldn’t need tax credits because they would be covered by the expansion of Medicaid. But the U.S. Supreme Court ruled in 2012 that the federal government couldn’t force states to expand.

Gov. Nathan Deal, a staunch Obamacare opponent, is among 19 governors who have declined to grow Medicaid under the terms of Obamacare; he estimates that expansion would cost Georgia taxpayers $2.5 billion over 10 years. (Advocates of expansion claim the cost would be far less.)

“I am not interested in growing entitlements, especially through an already broken and unsustainable Medicaid program dictated to the states by Washington,” Deal said in a statement to The Atlanta Journal-Constitution. “I am interested in real economic development where Georgians are better equipped to provide for themselves and their families rather than having to rely on government welfare programs like Medicaid.”

He added that the cost of expansion would have a “severe impact on public education.”

Medicaid in Georgia already covers about 1.7 million low-income children, pregnant women, the elderly and disabled. Expanding it would extend coverage to an estimated 650,000 people, most of them adults without children. Those who earn between 100 and 138 percent of the federal poverty line qualify for tax credits on the federal insurance marketplace. The vast majority (nearly 410,000), however, don’t qualify for tax credits or Medicaid or anything else.

The law envisioned that those under the poverty line would be eligible for Medicaid. And in many states, they are. Not in Georgia; indeed, not in most of the South. Kentucky and Arkansas both chose to expand.

Nationwide, 4.8 million uninsured Americans below poverty fall into this coverage gap. Eighty percent of them live in the South, with Georgia having the third-highest number of people behind Texas and Florida.

The fact that a single person who makes $12,000 a year is eligible for tax credits but someone who makes $500 isn’t turns normal thinking about the issue on its head, said Pat Ketsche, a health care expert at Georgia State University.

The ACA doesn’t help America’s poorest citizens in states that don’t expand, Ketsche said.

Without expansion, Georgia’s large numbers of uninsured will continue to flood emergency rooms, leading to higher medical bills and insurance premiums for those who do have coverage. Two of the state’s largest health care provider groups — the Medical Association of Georgia, representing doctors, and the Georgia Hospital Association — both support expanding Medicaid in some form.

“We have a safety net that will continue to try to patch together care for people,” Ketsche said. “But it’s a net. There are holes in it.”

‘A big ol’ stop sign that says no’

John David Vandiver always figured he’d work until he’s dead.

Self-employed for three decades, the Hoschton man worked trimming and removing trees. A car accident last summer, however, left him suffering from back pain and unable to work.

At 63, Vandiver is two years shy of qualifying for Medicare, the government health program for older Americans.

So he called the Health Insurance Marketplace only to be quoted monthly premiums ranging from $400 to $900 a month. That was far too steep for Vandiver — as much or more, in fact, than his entire monthly income (about $560 from Social Security).

He’d hoped for tax credits to help him buy insurance, but he makes too little to qualify for those.

Vandiver never imagined he would be in this position. Obamacare was supposed to be a good thing, he thought, but it hasn’t turned out anything like President Obama promised.

At least not for him.

“This whole deal went south on me,” he said. “People should qualify for something, but there’s a big ol’ stop sign that says no.”

‘The choice between food and medicine’

Nationwide, 14 percent of Americans who fall into the coverage gap are 55 to 64 — nearing retirement but, like Vandiver, not yet Medicare-eligible. Many suffer from chronic illnesses such as diabetes, high blood pressure and heart disease.

“There’s a whole bunch of people who are older with complex health care needs that aren’t being met,” said Lisa Dubay, a senior fellow with the Urban Institute.”In some cases, they’re making the choice between food and medicine.”

Adults under 65 with no dependents make up the vast majority of the gap population (about 78 percent here in Georgia.)

That’s in part because all of the states foregoing Medicaid expansion, except for Wisconsin, don’t offer benefits to the childless unless they’re severely disabled and very poor.

Being a parent doesn’t guarantee access to Medicaid either.

In Georgia, which has some of the strictest Medicaid eligibility standards in the country, a parent of three can’t make more than about $7,840 a year and still qualify for the program. In states that are expanding, both parents and people without kids who earn up to 138 percent of poverty, about $33,000 for a family of four, can now qualify.

Nearly two-thirds of those in the gap are people of color, according to the Kaiser Family Foundation. More than half are part of a family where at least one person works.

They are waiters and construction workers, cashiers and landscapers.

Many work but don’t get health insurance through their jobs, said Rachel Garfield, a senior researcher with Kaiser. Buying insurance on the Health Insurance Marketplace without the help of federal tax credits would eat up a third to half of their income — clearly outside the range of affordability, Garfield said.

Even people who do have Medicaid are in danger of losing that coverage if they start earning just a little bit more money, Garfield added. It may be a slightly higher income but still not enough to buy insurance while also putting food on the table.

“It’s not necessarily the most logical approach to extending coverage,” she said.

‘Without insurance, they’ll just send me home’

Anthony Jenkins has suffered from seizures for more than a decade.

The seizures make holding a steady job nearly impossible. At his last job, working in a warehouse for a sporting goods company, Jenkins said he lasted nine months before being let go for missing too much work because of the seizures.

“Every time I have a seizure it’s damaging my brain more and more,” he said. “If I had Medicaid, I could go to a neurologist.”

Maybe a specialist, he thinks, could help get the seizures under control and he could go back to work.

Obamacare champions argue extending Medicaid to Georgians like Jenkins would make them more productive workers with fewer sick days.

Health insurance can make the difference between someone being able to keep a steady job or losing everything, they say.

Previous expansions of Medicaid in other states have shown lower rates of depression, fewer premature deaths, more women getting mammograms and fewer individuals being hit with catastrophic medical bills, among other benefits, according to researchers with Harvard Medical School and The City University of New York.

But society tends to view the poor through a different lens than everyone else, said Cathryn Marchman with Saint Joseph’s Mercy Care Services.

“We don’t view somebody in poverty as somebody who also has something to lose,” she said.

Jenkins, 32, lives with a roommate in a sparse two-bedroom Atlanta apartment run by a nonprofit that helps men and women with mental illness get back on their feet. He’s bipolar and suffers from PTSD.

Mercy Care, a downtown clinic, has helped Jenkins get medication for bipolar disorder. But he hasn’t been able to see a neurologist who could treat the seizures in years. Meanwhile, he ends up in ERs, and the medical bills keep piling up.

“A lot of times hospitals want to keep me but without any insurance, they’ll just send me home,” Jenkins said. “If I can’t get the right help, then how can I get better?”

‘Putting state taxpayers on the hook’

The outlook is grim for Georgians stuck in the coverage gap.

Politicians on both sides of the aisle — many facing re-election this year — aren’t champing at the bit to come up with alternatives to Medicaid expansion.

Meanwhile, the state is losing out on federal funding: the feds will cover the full cost of expansion in 2014, 2015 and 2016. After that, the federal share gradually scales back to a permanent base of 9o percent.

Obamacare opponents have voiced concerns that the federal government, already overloaded with trillions of dollars in debt, won’t be able to hold up its end of the bargain and will leave states holding the bag.

Deal and top conservative leaders across the country have lobbied the White House to dole out Medicaid dollars in lump sums, called block grants, that would cap how much the federal government chips in for the program. In return, states would have fewer restrictions on how to run their programs.

“If Washington is serious about covering this population, it should send Georgia its federal share of the money,” Deal said. “We could go a long way toward covering this population without putting state taxpayers on the hook for exploding costs down the road.”

But the Obama administration opposes block grants, and expansion supporters say Deal’s decision is short-sighted. Not only will Georgia miss out on billions of dollars in new federal funding, they argue, but it will leave those most in need out in the cold.

“There’s a huge equity problem,” said Dubay with the Urban Institute. “It seems like a political decision and not a decision about taking care of the people in your state.”

$3,000 for a visit to the ER

Jen Rafanan, for one, isn’t happy to be caught in the political tug-of-war over the Affordable Care Act.

The freelance graphic designer hasn’t seen a doctor in a couple of years. Instead, at 38, she turns to the Internet and home remedies and hopes her symptoms go away on their own.

As a freelancer, Rafanan makes less than $10,000 a year and gets paid sporadically, making monthly insurance premium payments untenable. Even when she worked at a small printing company in Gainesville, her employer didn’t offer insurance.

She found a health clinic that treated low-income patients on a sliding payment scale, but lost hours — and money — at work because she was forced to wait for hours just to be seen for 10 or 15 minutes.

Several years ago, severe chest pains landed Rafanan in the ER. It turned out to be a panic attack, not a heart attack as she feared. She left the hospital relieved but with a $3,000 bill that took years to pay off.

Rafanan is upset that she and people who are in even worse situations are stuck.

Obamacare isn’t perfect, but at least it was a step in the right direction, Rafanan said. These are Georgians who work hard and pay taxes but don’t have as many opportunities as others, she said.

“It’s frustrating,” she said. “You’re pretty much screwed no matter which way you turn.”

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